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Delisted—Make Sure it Doesn’t Happen to You

What is Delisting Anyways?

Recently, a few PTs have called me shocked and embarrassed after discovering they’d been delisted by one, or more, of the major insurance providers.

Delisting of a physiotherapist by an insurance provider means the costs for services from the PT are no longer covered. Patients may be left to cover their own treatment costs and may go elsewhere for care. In many cases neither the PT nor the patient are notified of the delisting—not a pleasant surprise when you’re expecting a reimbursement.

Why are insurance providers delisting health professionals?

Fraud or abuse of benefits is big business, so it’s no surprise insurance companies have reacted by employing teams of investigators to gather data, conduct audits of health care facilities and use analytics to identify irregular billing patterns and potential fraud.
Fraud is an intentional deception that can result in unauthorized benefit. For example, submitting claims for services never given, falsifying claims or patient records, and frequency or description of services rendered.

Abuse, on the other hand, is defined as actions that are improper, inappropriate, outside of acceptable standards, or clinically unnecessary. Common examples of abuse include bad billing practices, failure to maintain accurate records and a pattern of claims for services not medically necessary.

I spoke with representatives from the insurance industry and they said audits that show evidence of the above examples, or a discipline history may trigger their decision to delist a PT. Audits of health facilities are increasing so there’s a good chance that if you’re working in, or own a private practice, you have or soon will participate in an audit. New grads or anyone new to physiotherapy should be careful when looking for work as there are some employers who make it difficult to follow the rules. Don’t get caught in someone else’s poor business practices and end up paying the price. Even if you change employers, there’s a chance you will remain delisted.

While the College has no power over insurance agencies and their decisions, we can increase your awareness. So, are you at risk of being delisted?

Ask yourself these eight questions:

Do I document in each patient file a correct physiotherapy diagnosis based on subjective and objective measures?

Do I develop and document a clear treatment plan?

Do I use outcome measures to support my rationale for treatment?

Do I document the dates a patient attended and the name of the person who provided the treatment?

Am I really supervising the care being delivered by PTAs or are they practicing independently?

Do I routinely check and document the accuracy of billing using my name and registration number?

Do I have an agreement with my employer as to the appropriate use of my name and registration number for billing purposes?

If I stop working at a clinic, do I have an agreement that no further invoices/claims will be made with my license after my date of departure?

Physiotherapsit communicate with insurance company About the illegal billing. Now, the clinic owner is accusing that patients are complaining about the physiotherapist. The clinic owner can create fake people and report the physiotherapist.

How can a physiotheraist be safe in such accusation?

Viivi Riis |Sep 21, 2018

I have just confirmed with CLHIA that health providers may communicate with extended health carriers concerning delisting and other issues related to fraud. Often, the delisting is not a decision made by the adjuster that you may interact with in processing a claim, but by a fraud unit or division at the company. Here is the page:

There is an email icon that permits you to email all insurers listed on that page. It also offers contact information for company fraud departments at individual insurers. So, for example, if a therapist has moved from a delisted clinic to another practice setting, you have the option of informing insurers that you are at a new practice. If you have purchased a clinic that was delisted under the previous owner's tenure, you can advise that there is new ownership and new policies/practices in place. It is also possible through this website to engage individual insurers about the reasons for delisting (although I can't comment on how responsive individual insurers will be).

Lisa |Aug 28, 2018

Very useful information.

Susan F |Jun 27, 2018

I see clients privately in their homes and recently had one client have his bill rejected by the insurance company. A letter from me stating my qualifications, my licensing number and years of experience and the fact that I am a sole practitioner not connected to any clinic resulted in a reversal of their rejection and the client was allowed to submit their bill for reimbursement. I now provide this letter to all private in home clients in case this happens to them.

Helen |Jun 24, 2018

Are the insurance companies delisting PTs actually looking at your list of quality standards of practice. Do they ask for the patient chart and review the quality of work or is this solely based on billing trending from a particular PT or practice? I am unsure how they would assess a person for delisting.

Fiona Campbell |Jun 23, 2018

Sameer, yes I can confirm both clinics and individual clinics can be delisted.

Fiona

Sameer |Jun 22, 2018

Great Post, any idea if clinics are being delisted, or just individual PTs?

Smith |Jun 21, 2018

Who knew this was happening? Interesting topic. I hope something can be done. This does not seem fair.